1801006106 - LONG CASE

 This is an online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent. Here we discuss our individual patient's problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problems with collective current best evidence based inputs. This e-log book also reflects my patient centered online learning portfolio and your valuable inputs on comment box is welcome. 

A 65 years old Man Who is Resident of Narketpally who was Alcohol Seller & Shepherd by Occupation Came with C/O 

Fever Since 3 Days cough since 3 days associated with weight loss , and shortness of breath.

History of presenting illness :

Apparently patient was asymptomatic 3 days back but then he developed fever since 3 days which is insidious in onset , low grade , progressive in nature , associated with chills and weight loss . . Then he also developed cough which is sudden in onset and associated with sputum and shortness of breath . 

No history of loose stools 

No history of vomitings , abdominal pain 

At 10 years of Age Patient Was apparently Asymptomatic Till 10 years of Age & Once day He Climbed & Fell Down While Cutting Tree leaves for feeding Their Goats & Had a Fracture of Lt.Forearm & Went to Nalgonda District Hospital where Cast was applied & After 20 days He developed infection & a part of Bone was Protruded out & That part of Bone was excised.

10 years Back : 

After Having a alcohol  Patient Developed Generalized Weakness & Got admitted in Our Hospital for 4-5 days

7 years Back : 

Patient Developed Giddiness & Went hospital & was diagnosed with DM2 & HTN for which he was Prescribed Tab.METFORMIN 500mg

6 Months Back : 

Patient Developed Both Lower Limb Swelling which was Pitting type & Upto Knees & Diagnosed to have Left Upper Ureter Calculi & CKD For which he was planned for Surgery But Couldn't not be done as patient wasn't fit for Surgery & Was Managed Conservatively with Tab.NODOSIS 500mg BD.He Has Dry Cough Occasionally Since 6 Months & 3 Days Back Then Had Fever with Chills Which was High Grade Continuous & Relieved on Taking Medications.

Past History: 

Patient Used to Sell Alcohol ( Sara) for almost 20 years & Used to Drink Daily the Same thing he used to Sell. Then he used to Drink 90-180ml of Whisky Till 6 Months Back & From Six Months He Drinks Occasionally During Festivals.

Known case of chronic kidney disease .

Similar episodes of fever lasting for 4-5 days which is relieved on medication.

Personal history :

Appetite : Decreased

Diet : Mixed

Bowel and bladder : Regular

Sleep : Adequate

Family history : not significant 

General examination:

Pt is conscious coherent and cooperative well oriented to time place and person

Pallor : Present

Cyanosis : Absent

Clubbing : Absent

Lymphadenopathy : Absent

Vitals :

Temperature : a febrile 

Blood pressure : 170/80mmhg 

Pulse rate : 130bpm

Respiratory rate : 15cycles per minute

Pedal Edema: pitting type extending upto knee joint 

Systemic examination: 

RESPIRATORY SYSTEM:

Inspection:

Shape- elliptical 

B/L symmetrical , 

Decreased movements on right side mammary region, infra scapular region  .

Engorged veins on the left side 

No scars, sinuses, pulsations 

Palpation:

Inspectory findings are confirmed 

Trachea - central

AP diameter 16 cm 

Transverse diameter 23 cm

Expansion of chest is symmetrical. 

Vocal fremitus - decreased on right side .

Percussion: 

Dull note on right mammary, interscapular infra axillary,  infrascapular

Auscultation:

 bilateral air entry present. Normal vesicular breath sounds heard. In all areas 

Decreased breath sounds on right mammary, interscapular ,infra axillary, infrascapular.

CARDIOVASCULAR SYSTEM:

Inspection:

        Shape of chest is elliptical.

        No raised JVP

        No visible pulsations, scars , sinuses , engorged veins.

Palpitation:

        Apex beat - felt at left 5th intercostal space

        No thrills and parasternal heaves

Auscultation :

  S1 and S2 heard. 

PER ABDOMEN:

Inspection :

       Umbilicus is central and inverted

       All quadrants are moving equally with respiration 

       No scars , sinuses , engorged veins, visible pulsations .

       Hernial orifices are free.

Palpitation :

       Abdomen is soft and non tender .

        No organomegaly.

Percussion :

       Tympanic note heard over the abdomen.

Auscultation:

Bowel sounds are heard.

CENTRAL NERVOUS SYSTEM:

on the day of presentation 

Conscious,coherent and cooperative 

Speech- normal

No signs of meningeal irritation. 

Cranial nerves- intact

Sensory system- normal 

Motor system:

Tone- normal

Power- bilaterally 5/5

Reflexes Right Left

Biceps ++ ++

Triceps ++ ++

Supinator ++ ++

Knee ++ ++

Ankle ++ ++

Investigations :

Hemoglobin : 7.6 gm 

Pleural fluid :

 ADA : 83.6 IU/L

Lights criteria : it is exudative type 

Microscopy : 

Smears shows many lymphocytes , few  neutrophils.

No atypical cells seen .

Impression : 

Suggestive of inflammatory cells seen..

Provisional diagnosis 

Right side pleural effusion?

RIGHT PLEURAL EFFUSION  exudative type , secondary to tb?.

With CKD stage 5 and anemia 

Treatment :

Anti tubercular drugs 

Isoniazid  5 mg/kg/weight

Rifampicin 10mg/kg/weight

Ethambutol 20 mg/kg/weight

Pyrazinamide 20-25 mg/kg/ weight 

4 tablets a day fixed dose .